Background
As the national conversation on health care becomes increasingly focused on end-of-life care and, more specifically, the quality of such care, states have become progressively interested in providing patients with a clear and efficient manner in which to direct their end-of-life care choices. On June 1, 2010, the New York State Department of Health updated its existing Medical Orders for Life Sustaining Treatment form, the MOLST form,1 to make it more user friendly and to align it with provisions of the Family Health Care Decisions Act (“FHCDA”)2. A MOLST form is generally for patients who have serious health conditions and have a life expectance of less than one year, want to state their wishes regarding life-sustaining treatment or patients who reside in long-term care facilities. The MOLST form is printed on bright “pulsar” pink heavy stock paper3 and is a medical order signed by a New York State (or a border state) physician.
MOLST v. Health Care Proxy v. Living Will
A Living Will and a Health Care Proxy are advance directives. Advance Directives are filled out by an individual over the age of 18, while that person has decision making capacity. These forms are only used once a person has lost his or her mental capacity. These forms contain general instructions and cannot be used by EMS providers in an emergency situation.
MOLST is not intended to replace a Living Will or Health Care Proxy. The medical orders in the MOLST form apply immediately and are not conditioned on a physician determination of the patient’s mental capacity. Additionally, the MOLST form may be used with minor patients. There are special instructions for completing the MOLST form with minor patients.4 There are numerous instructions for the completion of this form for adults which take into account the existence of other advance directives, FHCDA surrogates and the patient’s mental capacity.5
What does MOLST include?
The MOLST form includes patients’ goals and preferences regarding the following areas: (i) Resuscitation instructions when the patient has no pulse and/or is not breathing; (ii) Instructions for intubation and mechanical ventilation when the patient has a pulse and the patient is breathing; (iii) Treatment guidelines; (iv) Future hospitalization and transfer; (v) Artificially administered fluids and nutrition; (vi) Antibiotics; and (vii) Other instructions about treatments not listed.
The MOLST form must be completed based upon the patient’s current medical condition, values, wishes, and the informed consent by the patient or his/her health care decision-maker. At a minimum the physician must discuss with the patient and/or the patient’s health care decision-maker the patient’s diagnosis, prognosis, goals for care and treatment preferences. The conversation should be documented in the medical record. The physician must sign the MOLST form after completion.
Patients do not have to make all the decisions at once. The patient may elect to only fill out page one of the MOLST form (CPR/DNR) and make the remaining decisions at a later time. The physician should cross out any sections the patient has not decided upon and write “Decision Deferred.” If the patient reaches a decision at a later time, a new MOLST form must be completed.
Voluntary but Binding
It is voluntary for a patient to fill out a MOLST form. Additionally, a patient or the health care decision-maker may modify or void a MOLST fo